ARCHIVED - Summative Evaluation of the Blood Safety Contribution Program - Final Report

II. Blood Safety Contribution Program

BSCP Components

Component 2000: Transfusion Errors Surveillance System (TESS)

In 2004, four provinces (British Columbia, Ontario, Nova Scotia, and Quebec) began participating in a pilot project of the Transfusion Errors Surveillance System (TESS) to develop and implement a transfusion error reporting system in Canada.TESS is a web-based “no-fault” transfusion error tracking system.  Based on experience from the TTISS program, TESS focuses on the class of events, not due to problems with the product, but the errors associated with various procedural and laboratory steps required for safe administration of product.

From a resources point of view, TESS is considered a subset of TTISS. It is anticipated that TESS will evolve into a sentinel surveillance system to be used by hospitals and for benchmarking, rather than a comprehensive system in every province like TTISS. It appears that, ultimately, the goal is to develop an integrated, web based, national transfusion adverse event reporting system comprised of both TTISS and TESS. However, the two have not yet been integrated.

Current Status

To date, TESS activities have produced a system user manual (draft); an agreement for reporting on data; and minimum data elements. Currently, the PHAC is working on ensuring that legal issues relevant for the national expansion of TESS are addressed. A total of 11 small, medium and large hospitals from four provinces are currently participating in TESS.

The long-term goal is to develop an integrated, web based, national transfusion adverse event reporting system comprised of both TTISS and TESS.

Committee Support

TESS is supported by the National Working Group Transfusion Error Surveillance System (NWGTESS), which is comprised of 13 members.The NWGTESS was formed to establish an ongoing mechanism to ensure excellence in epidemiologic surveillance of serious errors/near misses related to blood transfusions. The group identifies and addresses issues related to a national surveillance program on the safety of blood, blood components and plasma derivatives, which are intended for use in the treatment of human diseases. The group serves the function of recommending future directions, quality, efficacy and effectiveness of the TESS as a national surveillance program. They are also responsible for informing and consulting the NWGTTISS on issues related to progress and implementation of TESS.